We classified autoimmune gastritis (AIG) into four stages-initial, early, active (intermediate), and advanced to terminal-and outlined the clinical, pathological, and endoscopic characteristics of each stage. First, we describe the stage-dependent changes and features of autoantibodies, gastrin, pepsinogen (PG) I, and the PG I/II ratio, key diagnostic clues and the characteristics of two types of anemia and anemia-related disorders. Next, we present the histopathological findings specific to each stage and their corresponding endoscopic appearances, emphasizing the importance of pathology-based endoscopic diagnosis. Finally, we discuss key issues related to gastric cancer associated with AIG, the relationship between AIG and Helicobacter pylori (H. pylori) infection, and the challenges in diagnosing H. pylori in AIG patients.

Background and aim: Endoscopic submucosal dissection (ESD) is an increasingly popular treatment for early gastric cancer. Although the greatest advantage of ESD is that it does not require surgical gastrectomy, there are cases in which gastrectomy is necessary after ESD. The frequency and characteristics of such cases are unclear.

Methods: We retrospectively reviewed the medical records to investigate the frequency and characteristics of cases that required surgical gastrectomy after ESD.

Results: Of the 886 cases analyzed, gastric cancer was newly detected after ESD in 160 cases (18.1%), and 23 cases (2.6%) required gastrectomy. 5-year survival rates without gastrectomy were 95.0%. Reasons for requiring gastrectomy included missed endoscopies before and after ESD, interrupted hospital visits, and tumors in other organs.

Conclusion: It is important to continue high-quality endoscopic examination after ESD and to recognize that some cases may require surgical gastrectomy that cannot be prevented.

A 22-year-old man was diagnosed as ulcerative colitis (UC), and was referred because he was refractory to 5-aminosalicylic acid (5-ASA). After examination, he was considered to active UC, Clostridioides difficile infection (CDI), 5-ASA intolerance. He went into remission with discontinuation of 5-ASA, administration of corticosteroids, vancomycin. The symptoms of 5-ASA intolerance, CDI are similar to UC and require careful attention in diagnosis and treatment.

A 78-year-old man with known cardiovascular disease presented with sudden epigastric pain. Based on elevated serum pancreatic amylase level and contrast-enhanced CT findings of pancreatic swelling without necrosis, he was diagnosed as having mild acute pancreatitis. We promptly commenced aggressive fluid therapy of approximately 4 L/day. However, his abdominal pain persisted and required frequent analgesic administration. Eighteen hours after presentation, he suffered altered consciousness and acute hypotension, leading to death 24 hours post-presentation.

A pathological autopsy revealed inflammatory changes in the pancreas, particularly in the pancreatic body, as well as extensive small intestinal necrosis. No thrombi were detected in the mesenteric arteries or veins, suggesting a non-occlusive mechanism of ischemia. In addition, gas formation was observed in the intestinal submucosa, muscle layer, and portal vein. Despite the initial diagnosis of mild acute pancreatitis, the patient was ultimately judged to have died from complications of non-occlusive mesenteric ischemia leading to septic shock.

This rare case highlights the importance of considering intestinal ischemia even in mild acute pancreatitis, especially in patients with a history of cardiovascular disease. It also emphasizes the need for careful monitoring and prompt diagnostic measures, including contrast-enhanced CT, in patients showing an atypical clinical course or rapid deterioration.